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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 30 Results
WebM&M Case February 1, 2013
After delivering a healthy infant via Caesarean section, a young woman was to receive morphine via PCA pump. A mix-up in programming the concentration of medication delivered by the pump led to a fatal outcome.
Pham JC, Story JL, Hicks RW, et al. J Emerg Med. 2011;40:485-92.
A 2006 Institute of Medicine report highlighted growing concerns about the state of emergency department (ED) care, particularly around overcrowding and its impact on safety. Medication errors are a known safety threat, and this study provides a cross-sectional perspective using reports from the MEDMARX database. Investigators found that physicians were responsible for 24% of errors while nurses were responsible for 54%. The administration phase was the most error-prone, and the most common error type was improper dose/quantity. Interestingly, computerized provider order entry was noted to cause 2.5% of the errors reported. The authors advocate for future interventions to improve medication safety in the ED. A past AHRQ WebM&M commentary discussed a near miss medication error in the ED that illustrates the many safety issues that contribute to this high-risk care setting.
Grissinger MC, Hicks RW, Keroack MA, et al. Jt Comm J Qual Patient Saf. 2010;36:195-202.
Patient safety reporting systems are commonplace in most organizations as a tool to identify, track, and potentially prevent adverse events despite their known limitations. Heparin is a high-risk medication that frequently generates incident reports, and significant efforts have been established to ensure its safe use. This study reviewed reported heparin errors from three large patient safety reporting systems—MEDMARX, the Pennsylvania Patient Safety Authority, and the University Health Consortium (an alliance of academic medical centers)—to capture events from more than 1000 organizations. Of the 300,000 medication events reported, approximately 4% involved heparin products, with the administration phase being the most frequently cited. As this was the first study to combine three large sources of reporting data for a single process, the authors point out the consistent patterns detected, suggesting diminishing returns from aggregating reports around common events.
Alexander DC, Bundy DG, Shore AD, et al. Pediatrics. 2009;124:324-32.
This study found that diuretics and antihypertensives were the most frequent medications reported in pediatric errors, and improper dosing was the most common type of administration error. However, error severity did not differ significantly by age or medication type.
Guenter P, Hicks RW, Simmons D. Nutr Clin Pract. 2009;24:325-34.
This review surveys information on enteral nutrition administration and tubing misconnections and recommends employing increased standards and forcing functions to reduce their incidence.
Williams T, Acton C, Hicks RW. Nurs Manage. 2008;39:54-7.
This commentary describes how one medical center developed a medication reconciliation program involving a multidisciplinary team.
Hicks RW, Sikirica V, Nelson W, et al. Am J Health Syst Pharm. 2008;65:429-40.
The use of patient-controlled analgesia (PCA) is an important method to treat pain, but concerns about its safety and device selection have been raised. This study examined nearly 10,000 PCA-related medication errors submitted to MEDMARX, a database that tracks medication information from participating hospitals. Investigators discovered that patient harm was associated with 6.5% of the errors, and the errors overall were reported across all phases of the medication process. The most common errors were related to improper dosage or quantity. An AHRQ WebM&M commentary discusses a case of a PCA overdose and the mechanisms to promote its safe use.
Lipshutz AKM, Morlock LL, Shore AD, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;34.
This study describes medication error types that occur in “code” situations and also highlights their impact on other patients (referred to as “collateral damage errors” by the authors). Using data from MEDMARX, a voluntary reporting database that tracks medication information from participating hospitals, investigators evaluated more than 2000 code-related errors. Omission errors were the most common error type, registered nurses and respiratory therapists were most frequently involved (though also the most likely to prevent errors), and anti-asthma/bronchodilator medications were the most common therapeutic class implicated. The authors provide a number of anecdotes to illustrate the relationship of the errors to the code situation, and detail the level of harm and common contributing factors reported. Finally, a series of preventive strategies are offered to reduce code-related medication errors, including redundant staffing to prevent collateral damage errors, and the use of DNR identification systems and rapid response systems to reduce code frequency.
Zhan C, Smith SR, Keyes MA, et al. Jt Comm J Qual Patient Saf. 2008;34:36-45.
Warfarin therapy is frequently associated with adverse drug events. Past efforts to identify potential prevention strategies have focused on using specific indicators or triggers to detect such events. This study examined more than 9000 errors in warfarin use submitted voluntarily through MEDMARX, a database that tracks medication information from participating hospitals. Investigators discovered that inpatient warfarin-related errors occurred most frequently during transcription/documentation and administration, while outpatient errors occurred most frequently during prescribing and dispensing. Using warfarin data as an example, the authors discuss the utility of voluntary error reporting systems and outline the limitations in their use.
Brunetti L, Santell JP, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:576-83.
Avoiding use of unclear or misleading abbreviations is a key step in preventing medication prescribing errors, and the Joint Commission mandates avoiding specific abbreviations as one of its National Patient Safety Goals. This study analyzed Medmarx data from 2004 to 2006 to determine the prevalence and impact of errors related to abbreviations. Despite dissemination of the Joint Commission's “do not use” abbreviation list, errors involving these abbreviations occurred more than 18,000 times during the study period, although few patients were harmed as a result.
Rinke ML, Shore AD, Morlock L, et al. Cancer. 2007;110:186-95.
Although adverse drug events (ADEs) are relatively frequent in outpatient chemotherapy, little is known about ADE rates in pediatric cancer patients. This study examined data from the Medmarx voluntary reporting system to characterize the frequency and severity of such errors in pediatric patients. More than 300 errors were reported over the 5-year study period, approximately 15% of which resulted in clinical consequences (ie, the need for additional patient monitoring or therapeutic intervention). Errors in administering medications were the most common cause of adverse events, as noted in a previous study. The authors note that these errors probably would not be prevented by safety interventions such as computerized physician order entry.